Citation Nr: 0109144
Decision Date: 03/28/01 Archive Date: 04/03/01
DOCKET NO. 00-02 968 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Winston-
Salem, North Carolina
THE ISSUES
1. Entitlement to service connection for joint and muscle
pain of the neck and shoulders claimed as chronic disability
resulting from an undiagnosed illness.
2. Entitlement to service connection for joint pain of the
left knee claimed as a chronic disability resulting from an
undiagnosed illness.
3. Entitlement to service connection for joint and muscle
pain, and swelling, of the right ankle claimed as chronic
disability resulting from an undiagnosed illness.
4. Entitlement to service connection for cervical
osteoarthritis.
5. Entitlement to service connection for the postoperative
degenerative joint disease, left knee.
6. Entitlement to service connection for early degenerative
joint disease, right ankle.
7. Entitlement to service connection for headaches, claimed
as a chronic disability resulting from an undiagnosed
illness.
8. Entitlement to service connection for short-term memory
loss, claimed as a chronic disability resulting from an
undiagnosed illness.
9. Entitlement to service connection for rashes and sores,
claimed as a chronic disability resulting from an undiagnosed
illness.
REPRESENTATION
Appellant represented by: The American Legion
ATTORNEY FOR THE BOARD
J. A. Markey, Counsel
INTRODUCTION
The veteran served on active duty or active duty for training
from July to December 1978, and from September 1990 to May
1991. Between these periods of service, the veteran served
for over 10 years with the United States Army Reserves
(USAR).
These matters come before the Board of Veterans' Appeals
(Board) from an October 1998 decision by the Department of
Veterans Affairs (VA) Regional Office (RO) in Winston-Salem,
North Carolina, which denied the veteran's claims of
entitlement to service connection for cervical osteoarthritis
also claimed as joint and muscle pain of the neck and
shoulders as a chronic disability resulting from an
undiagnosed illness; for postoperative degenerative joint
disease, left knee, also claimed as joint pain of the left
knee as a chronic disability resulting from an undiagnosed
illness; for early degenerative joint disease, right ankle,
also claimed as joint and muscle pain, and swelling, of the
right ankle as a chronic disability resulting from an
undiagnosed illness; for headaches, claimed as a chronic
disability resulting from an undiagnosed illness; for short
term memory loss, claimed as a chronic disability resulting
from an undiagnosed illness; and for rashes and sores,
claimed as a chronic disability resulting from an undiagnosed
illness.
FINDINGS OF FACT
1. As the veteran has been diagnosed as having cervical
osteoarthritis and degenerative changes in the right
shoulder, the evidence does not support his allegation that
his joint and muscle pain of the neck and shoulders
constitutes a chronic disability resulting from an
undiagnosed illness.
2. As the veteran has been diagnosed as having postoperative
degenerative joint disease, left knee, the evidence does not
support his allegation that his joint pain of the left knee
constitutes a chronic disability resulting from an
undiagnosed illness.
3. As the veteran has been diagnosed as having early
degenerative joint disease, right ankle, the evidence does
not support his allegation that his joint and muscle pain,
and swelling, of the right ankle constitutes a chronic
disability resulting from an undiagnosed illness.
CONCLUSIONS OF LAW
1. Service connection for joint and muscle pain of the neck
and shoulders as chronic disability resulting from an
undiagnosed illness is not warranted. 38 U.S.C.A. § 1117
(West 1991 Supp. 2000); 38 C.F.R. § 3.317 (2000).
2. Service connection for joint pain of the left knee as a
chronic disability resulting from an undiagnosed illness is
not warranted. 38 U.S.C.A. § 1117 (West Supp. 2000);
38 C.F.R. § 3.317 (2000).
3. Service connection for joint and muscle pain, and
swelling, of the right ankle as chronic disability resulting
from an undiagnosed illness is not warranted. 38 U.S.C.A.
§ 1117 (West 1991 and Supp. 2000); 38 C.F.R. § 3.317 (2000).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
Introduction
The veteran and his representative contend that service
connection is warranted for joint and muscle pain of the neck
and shoulders, joint pain of the left knee, and for joint and
muscle pain, and swelling, of the right ankle, which are all
related to his period of active service in the Southwest Asia
Theater of operations during the Persian Gulf War. The Board
points out that, as noted above, the veteran served on active
duty from July to December 1978, and from September 1990 to
May 1991.
Title 38 U.S.C.A. Section 1117 provides in pertinent part:
(a) The Secretary may pay compensation
under this subchapter to any Persian
Gulf veteran suffering from a chronic
disability resulting from an undiagnosed
illness (or combination of undiagnosed
illnesses) that
(1) became manifest during service
on active duty in the Armed Forces in
the Southwest Asia theater of operations
during the Persian Gulf War; or
(2) became manifest to a degree of
10 percent or more within the
presumptive period prescribed under
subsection (b).
(b) The Secretary shall prescribe by
regulation the period of time following
service in the Southwest Asia Theater of
operations during the Persian Gulf War
that the Secretary determines is
appropriate for presumption of service
connection for purposes of this section.
* * *
(e) For purposes of this section, the
term ''Persian Gulf veteran" means a
veteran who served on active duty in the
Armed Forces in the Southwest Asia
theater of operations during the Persian
Gulf War.
38 U.S.C.A. § 1117 (West Supp. 2000).
The regulation implementing the foregoing statute, 38 C.F.R.
§ 3.317, provides in relevant part that except as provided
otherwise, VA shall pay compensation in accordance with
Chapter 11 of Title 38, United States Code, to a Persian Gulf
veteran who exhibits "objective indications of chronic
disability resulting from an illness or combination of
illnesses" manifested by one or more signs or symptoms, such
as joint and muscle pain, and other symptoms, provided that
such disability (i) became manifest either during active duty
in the South West Asia theater of operations during the Gulf
War, or to a compensable degree no later than December 31,
2001, and (ii) by history, physical examination, and
laboratory tests cannot be attributed to any known clinical
diagnosis. 38 C.F.R. § 3.317(a)(1) (2000).
"Objective indications of chronic disability" include both
"signs" in the medical sense of objective evidence
perceptible to an examining physician, and other, non-medical
indicators that are capable of independent verification. 38
C.F.R. § 3.317(a)(2) (2000). Disabilities that have existed
for at least 6 months, and disabilities that exhibit
intermittent episodes of improvement and worsening over a 6-
month period will be considered "chronic." Id.
Factual Background
As noted, the veteran served on active duty or active duty
for training from July to December 1978, and from September
1990 to May 1991, and in between these periods served with
the USAR. The evidence of record reflects that he served in
the Southwest Asia Theater of operations and that he was
awarded the Southwest Asia Service Medal. The veteran's
service medical records covering his latter period of service
are negative for treatment or complaints of joint and muscle
pain of the neck, shoulders, left knee, or right ankle, or
swelling of the right ankle.
Other service medical records (to include those dated during
his reserve service) indicate that the veteran presented in
August 1978 complaining of pain in the right ankle, left
knee, and both shoulders. There was no swelling noted and
range of motion of all joints was full. In September 1978 he
presented with slight right ankle swelling and noted that he
had twisted the ankle in July of that year; X-rays taken
showed evidence of old trauma or possibly an accessory bone
on the medial aspect of the talus (otherwise the ankle was
normal). In June 1980 the veteran presented with a twisted
right ankle and injured right shoulder, and was diagnosed
with a muscle strain. In August 1981 the veteran presented
with complaints of neck and shoulder pain since injuring the
shoulder. X-rays of the right shoulder were within normal
limits, but of the neck showed osteophytes at the C3-4 and
C4-5 levels bilaterally. The veteran was diagnosed early
osteoarthritis of the cervical spine not secondary to injury.
VA outpatient treatment records reflect that in January 1996
the veteran was diagnosed with degenerative joint disease of
the cervical spine with pain and stiffness. In November
1996, he was seen after an abnormal bone scan which showed
hot spots in the left knee and right foot, and was diagnosed
with diffuse degenerative joint disease. It was noted in
this report that degenerative joint disease of the left knee
resulted from a dislocated patella with subsequent surgery.
X-rays of the cervical spine taken in December 1996 revealed
narrowing at the C6-7 level, anterior marginal lipping at the
C5-6 level, and encroachment of neural foramina at the C3-4
level.
A VA general medical examination was accomplished in January
1997, the report of which reflects that the veteran's
complaints included muscle and joint aches, ankle swelling on
prolonged standing, and discomfort of the left knee since
surgery in 1995 for a kneecap problem. Physical examination
revealed full range of motion of both the left knee and right
ankle, and X-rays showed a minor osteophyte of the left
patella and possible old trauma medially with some small
tissue ossification of the right ankle. As a result of this
examination, the veteran was diagnosed with, among other
things, muscle and joint pains (it was noted to refer to the
X-rays), right ankle discomfort with X-ray changes noted, and
left knee surgery with discomfort, with X-rays showing some
degenerative changes of the left patella.
Another VA examination was accomplished in September 1997,
the report of which notes that the veteran gave a history of
injuring his right leg, shoulders, and neck in a truck
accident during the Persian Gulf War. Further, he gave a
history of straining his right ankle in 1982 and noted
intermittent pain since then. He also noted having had left
knee surgery in 1994 due to a dislocated patella, and that he
still has occasional knee and scar pain.
During the examination, the veteran complained of left sided
cervical pain, left shoulder pain, some weakness in the left
hand associated with numbness and tingling, and pain in the
right ankle and foot on walking and standing. Physical
examination revealed tenderness over the left
acromioclavicular joint with painful motion, a normal right
shoulder, right ankle tenderness, and a well healed,
nontender scar about the left knee. X-rays showed mild
degenerative changes at the C5-6 level and minor left knee
osteophytes, as well as minimal degenerative changes of the
shoulders.
As a result of this examination, the veteran was diagnosed
with, among other things, degenerative arthritis C5-6 with
mild left radiculopathy, status post left knee surgery for
dislocated patella, mildly symptomatic degenerative joint
changes of the left shoulder, and status post right ankle
injury 1982, with clinical evidence of early arthritic
changes causing pain on walking.
Analysis
Initially, the Board finds that the evidence satisfactorily
demonstrates that the veteran served in the Southwest Asia
Theater of operations during the Persian Gulf War.
However, entitlement to service connection for joint and
muscle pain of the neck and shoulders, joint pain of the left
knee, and for joint and muscle pain, and swelling, of the
right ankle, as chronic disabilities resulting from
undiagnosed illnesses, is not warranted. The claims file
clearly indicates that the veteran has been diagnosed as
having, among other things, arthritis of the cervical spine
with mild left radiculopathy, status post left knee surgery
for dislocated patella, mildly symptomatic degenerative joint
changes of the left shoulder, and status post right ankle
injury with arthritis.
As noted, VA shall pay compensation in accordance with
Chapter 11 of Title 38, United States Code, to a Persian Gulf
veteran who exhibits "objective indications of chronic
disability resulting from an illness or combination of
illnesses" manifested by one or more signs or symptoms, such
as joint and muscle pain, and other symptoms, provided that
such disability (i) became manifest either during active duty
in the South West Asia theater of operations during the Gulf
War, or to a compensable degree no later than December 31,
2001, and (ii) by history, physical examination, and
laboratory tests cannot be attributed to any known clinical
diagnosis. 38 C.F.R. § 3.317(a)(1) (2000). Here, it is
clear that the veteran's cervical spine, left knee, and right
ankle disabilities are attributable to known clinical
diagnoses. As such, service connection for these alleged
chronic disabilities resulting from undiagnosed illnesses is
not warranted.
Finally, the Board notes that recently, Congress amended
38 U.S.C.A. § 5107 (and amended or added other relevant
provisions) to reflect that VA has a duty assist a claimant
in developing all facts pertinent to a claim for benefits.
Such duty includes requesting information as described in
38 U.S.C.A. § 5106, as well as the accomplishment of a
medical examination when such examination may substantiate
entitlement to the benefits sought. A claim may be decided
without providing such assistance only when no reasonable
possibility exists that such assistance will aid in the
establishment of entitlement, or the record includes medical
evidence sufficient to adjudicate the claim. See Veterans
Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat.
2096 (2000) (to be codified at 38 U.S.C. §§ 5102, 5103,
5103A, and 5107).
Regarding these claims, no further assistance is necessary
because as the veteran has been diagnosed with the above
orthopedic disabilities (i.e. they are attributable to known
clinical diagnoses), no reasonable possibility exists that
such assistance will aid in the establishment of entitlement
to service connection for alleged chronic disabilities
resulting from undiagnosed illnesses.
ORDER
The claim for service connection for joint and muscle pain of
the neck and shoulders as chronic disability resulting from
an undiagnosed illness is denied.
The claim for service connection for joint pain of the left
knee as chronic disability resulting from an undiagnosed
illness is denied.
The claim for service connection for joint and muscle pain,
and swelling, of the right ankle as chronic disability
resulting from an undiagnosed illness is denied.
REMAND
Generally, applicable law provides that service connection
will be granted if it is shown a particular disease or injury
resulting in disability was incurred or aggravated during
active duty or active duty for training. 38 U.S.C.A. § 1110
(West 1991 & Supp. 2000); 38 C.F.R. § 3.303 (2000). Further,
and as noted above, VA shall pay compensation in accordance
with Chapter 11 of Title 38, United States Code, to a Persian
Gulf veteran who exhibits "objective indications of chronic
disability resulting from an illness or combination of
illnesses" manifested by one or more signs or symptoms, such
as joint and muscle pain, and other symptoms, provided that
such disability (i) became manifest either during active duty
in the South West Asia theater of operations during the Gulf
War, or to a compensable degree no later than December 31,
2001, and (ii) by history, physical examination, and
laboratory tests cannot be attributed to any known clinical
diagnosis. 38 C.F.R. § 3.317(a)(1) (2000).
Recently, and as noted above, Congress amended 38 U.S.C.A.
§ 5107 (and amended or added other relevant provisions) to
reflect that VA has a duty assist a claimant in developing
all facts pertinent to a claim for benefits. Such duty
includes requesting information as described in 38 U.S.C.A.
§ 5106, as well as the accomplishment of a medical
examination when such examination may substantiate
entitlement to the benefits sought. A claim may be decided
without providing such assistance only when no reasonable
possibility exists that such assistance will aid in the
establishment of entitlement, or the record includes medical
evidence sufficient to adjudicate the claim. See Veterans
Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat.
2096 (2000) (to be codified at 38 U.S.C. §§ 5102, 5103,
5103A, and 5107).
As regards the veteran's claims for service connection for
headaches, short term memory loss, and rashes and sores, the
Board notes that he and his representative contend that such
conditions are related to the veteran's period of active
service in the Southwest Asia theater of operations during
the Persian Gulf War.
The Board notes that claims for service connection for
chronic disability resulting from Persian Gulf service (and
due to an undiagnosed illness) related to exposure to
environmental agents while in the Persian Gulf are subject to
the adjudicative procedures set forth in M21-1, Part III,
para. 5.17 (April 30, 1999). In essence, the RO, upon
receipt of a veteran's claim, is to undertake all required
development action, including requesting a thorough VA
general medical examination and specialist examinations as
appropriate. With regard to nonmedical (lay) evidence, it is
noted that records or reports of time lost from work, changes
in physical appearance, changes in physical abilities, and
changes in mental and emotional attitude are helpful in
support of a Persian Gulf War claim.
VBA All-Stations Letter 98-17 (2/26/98) contained mandatory
guidelines for disability examinations of Gulf War veterans
outlined in a memorandum dated February 6, 1998. In general,
the guidelines require a VA examiner to detail all conditions
and symptoms that can be elicited from the veteran (including
what precipitates and what relieves them). The examiner
should then identify all diagnosed conditions arising from
the symptoms, and also determine if there are symptoms,
abnormal physical findings, or abnormal laboratory test
results that are not part of a known clinical diagnosis. In
that case, further specialist examinations are required to
address these findings. The guidelines also state that
symptom-based diagnoses, such as (but not limited to)
myalgia, arthralgia, headache and diarrhea, are not
considered as diagnosed conditions for compensation purposes.
The Board notes, however, that the VBA All-Stations Letter
98-17 (February 26, 1998), discussed above has since been
rescinded, effective December 31, 1998. The guidelines for
disability examinations for Gulf War Veterans have been
issued in an Under Secretary for Health's Information Letter,
dated April 28, 1998 (IL 10-98-010). These new guidelines
are essentially the same as the old guidelines and do not
represent any substantive change.
The Board finds that the veteran should be afforded
additional examination(s) that sufficiently addresses the
extent and nature of his complaints regarding headaches,
short-term memory loss, and rashes and sores. It is noted
that while the evidence of record reflects that the veteran
has complained of and has been "diagnosed" with headaches
and short term memory loss on numerous occasions, as well as
rashes (although not present), there are no objective
comments either way regarding these conditions. The Board is
of the opinion that an additional examination(s) that
addresses these conditions should be accomplished prior to
further adjudication.
In sum, further evaluation of these claimed disabilities
(headaches, short-term memory loss, and rashes and sores), to
ensure compliance with undiagnosed illness examination
directives, would be helpful in resolving all the issues on
appeal. Accordingly, the Board finds that additional VA
examinations should be accomplished. The new VA
examination(s) of the veteran must be conducted in accordance
with the guidelines of the Under Secretary for Health's
Information Letter, dated April 28, 1998 (IL 10-98-010). The
RO is advised to make certain that the examinations conform
precisely to the guidelines before readjudicating the issues.
The veteran and his representative also contend that service
connection is warranted for cervical osteoarthritis,
postoperative degenerative joint disease, left knee, and for
early degenerative joint disease, right ankle. The Board
notes that while it appears that the veteran may indeed
currently suffer from these disabilities, none of the medical
evidence of record contains a definitive opinion as to
whether any of these disabilities are related to his service.
Under these circumstances, and to comply with the dictates of
the Veterans Claims Assistance Act of 2000, the Board finds
that VA examinations by appropriate specialists should be
accomplished in order to obtain opinions with respect to the
etiology of the cervical osteoarthritis, postoperative
degenerative joint disease, left knee, and for early
degenerative joint disease, right ankle.
The veteran is hereby advised that failure to report to any
such scheduled examination, without good cause, may well
result in a denial of the claim(s). See 38 C.F.R. § 3.655
(2000). Examples of good cause include, but are not limited
to, the illness or hospitalization of the claimant and death
of an immediate family member. Id.
Further, with respect to the left knee disability, while the
record reflects that the veteran underwent left knee surgery
in 1994 or 1995, records of this procedure have not been
associated with the claims folder. These records, as well as
all other outstanding pertinent medical records, should be
obtained and associated with the record before the RO
arranges for the veteran to undergo further examination.
In view of all of the above, these matters are hereby
REMANDED to the RO for the following action:
1. The RO should take the appropriate
steps to obtain and associate with the
record all outstanding pertinent medical
records from all pertinent VA medical
facilities (to include records pertaining
to his 1994 or 1995 knee surgery), as
well as records from any other source(s)
or facility(ies) identified by the
veteran. If any requested records are
not available, or the search for such
records otherwise yields negative
results, that fact should be noted in the
veteran's claims file, and he and his
representative so notified. The veteran
is also free to submit any pertinent
medical or other records in his
possession, and the RO should afford him
the opportunity to do so before the
arranging for him to undergo further
examination.
2. The RO should also contact the
veteran and request that he submit signed
statements from persons having personal
knowledge of his disabilities which
include the following statement:
"I hereby certify that the information I
have given is true to the best of my
knowledge and belief."
The veteran should be notified that
statements from persons who knew him
during the Persian Gulf War or after
separation from military service will be
considered. Each person's name and
complete address must clearly be shown.
Each statement should describe exactly
what the person observed and mention
specific dates and places. A person on
active duty at the time should include
his or her service number and military
unit.
3. After associating with the claims
file all records received pursuant to the
development requested in paragraphs 1 and
2, the RO should have the veteran
scheduled for comprehensive VA orthopedic
examination in order to ascertain the
nature and severity of his cervical
osteoarthritis, postoperative
degenerative joint disease, left knee,
and early degenerative joint disease,
right ankle. It is imperative that the
physician(s) designated to examine the
veteran undertakes a review of the
evidence in his claims folder, including
a complete copy of this REMAND. Each
examination report should reflect
consideration of the veteran's
documented, relevant medical history.
All appropriate tests and studies (to
include X-rays) should be conducted, and
all clinical findings and diagnoses
should be reported in detail.
Each examiner is requested to offer an
opinion as to whether it is at least as
likely as not that any diagnosed cervical
spine osteoarthritis, left knee
disability (leading to postoperative
degenerative joint disease, left knee),
or early degenerative joint disease of
the right ankle, as appropriate, was/were
incurred or aggravated during the
veteran's active duty service or active
duty for training. All examination
findings, along with the complete
rationale for each opinion expressed and
conclusion reached (to include, as
appropriate, citation to specific
evidence of record), must be set forth in
(a) typewritten report(s).
4. The veteran should also be scheduled
to undergo a VA examination(s) conforming
to the guidelines for conducting Gulf War
examinations set forth in the Under
Secretary for Health's Information
Letter, dated April 28, 1998 (IL 10-98-
010). The entire claims folder,
including a complete copy of this REMAND,
must be made available to, and be
reviewed by, each physician designated to
examine the veteran.
a. Each examiner should thoroughly
review the claims file prior to the
examination.
b. The examiner should note and detail
all reported headaches, short-term memory
loss, and signs or symptoms involving the
skin. The examiner should conduct a
comprehensive general medical
examination, and provide details about
the onset, frequency, duration, and
severity of all symptoms and state what
precipitates and what relieves them.
c. The examiner should list all
diagnosed conditions and state which
symptoms are associated with each
condition. If all symptoms are
associated with a diagnosed condition,
additional specialist examinations for
diagnostic purposes are not needed.
d. However, if the veteran suffers from
headaches, short term memory loss, and
rashes and sores (signs or symptoms
involving the skin) that have not been
determined to be associated with a known
clinical diagnosis, further specialist
examinations will be required to address
these findings, and should be ordered by
the primary examiner.
e. In such instances, the examiner
should provide the specialist with all
examination reports and test results,
specify the relevant symptoms that have
not been attributed to a known clinical
diagnosis and request that the specialist
determine which of these, if any, can be
attributed in this veteran to a known
clinical diagnosis and which, if any,
cannot be attributed in this veteran to a
known clinical diagnosis.
All examination findings, along with the
complete rationale for each conclusion
reached and opinion expressed, should be
set forth in (a) typewritten report(s).
5. To help avoid future remand, the RO
should ensure that all requested
development has been completed (to the
extent possible) in compliance with this
REMAND. If any action is not undertaken,
or is taken in a deficient manner,
appropriate corrective action should be
undertaken. See Stegall v. West, 11 Vet.
App. 268 (1998).
6. The RO must also review the claims
file and ensure that all notification and
development action required by the
Veterans Claims Assistance Act of 2000,
Pub. L. No. 106-475 is completed. In
particular, the RO should ensure that the
new notification requirements and
development procedures contained in
sections 3 and 4 of the Act (to be
codified as amended at 38 U.S.C.A.
§§ 5102, 5103, 5103A, and 5107) are fully
complied with and satisfied.
7. Following completion of the
foregoing, and any other development
deemed warranted by the record, the RO
should consider the remaining claims on
appeal on the basis of all pertinent
medical evidence of record and legal
authority, to specifically include that
cited to herein. The RO should provide
clear reasons and bases for its
determinations, addressing all concerns
noted in this REMAND.
8. If any claim remains denied, the
veteran and his representative should be
provided with an appropriate supplemental
statement of the case and afforded the
applicable time period for response
before the claims file is returned to the
Board for further appellate
consideration.
The purpose of this REMAND is to afford due process and to
accomplish additional development and adjudication; it is not
the Board's intent to imply whether the benefits requested
should be granted or denied. The veteran need take no action
until otherwise notified, but he may furnish additional
evidence and/or argument during the appropriate time frame.
See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v.
Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8
Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129,
141 (1992).
These claims must be afforded expeditious treatment by the
RO. The law requires that all claims that are remanded by
the Board of Veterans' Appeals or by the United States Court
of Appeals for Veterans Claims for additional development or
other appropriate action must be handled in an expeditious
manner. See The Veterans' Benefits Improvements Act of 1994,
Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994),
38 U.S.C.A. § 5101 (West Supp. 2000) (Historical and
Statutory Notes). In addition, VBA's Adjudication Procedure
Manual, M21-1, Part IV, directs the ROs to provide
expeditious handling of all cases that have been
JACQUELINE E. MONROE
Member, Board of Veterans' Appeals